Pediatric Acute Lung Injury Consensus Research Articles

Acute respiratory distress syndrome in pediatric practice, diagnosis, and intensive care: A review

Acute respiratory distress syndrome is one of the main causes of life-threatening complications and deaths in pediatric intensive care units. This study aimed to analyze the current features of epidemiology, risk factors, and outcomes of acute respiratory distress syndrome in children aged 1 months according to the literature. The analysis included 100 publications extracted from eLibrary and PubMed abstract databases. The search was performed using the following keywords: acute respiratory distress syndrome, epidemiology, pediatric, outcome, and control mechanical ventilation. After the initial study of abstracts, 64 articles containing previously published information were excluded from the review. The recommendations of the Pediatric Acute Lung Injury Consensus Conference, which were published in April 2023, were taken as the main source. The review presents current definitions, risk factors, and criteria for the severity of acute respiratory distress syndrome in pediatric practice, discusses in detail the features of invasive ventilation and adjuvant therapy, and pays special attention to infusion and transfusion therapy, nutrition, and sedation. One of the sections is devoted to monitoring the patient’s condition, assessing the effectiveness of gas exchange and hemodynamics, and emphasizing the importance of a dynamic assessment of delirium in patients and the readiness for extubation. The recommendations of Pediatric Acute Lung Injury Consensus Conference-2 for the treatment of acute respiratory distress syndrome in children make it possible to more accurately stratify the severity of the pathological process, identify patients at risk with a high probability of developing this syndrome, and begin timely protective respiratory support to restore lung parenchyma and optimize oxygen delivery and consumption.

Definition, Incidence, and Epidemiology of Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference: Erratum.

Definition, Incidence, and Epidemiology of Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference: Erratum.

The perinatal period should be considered in neonatal acute respiratory distress syndrome: comparison of the Montreux definition vs. the second pediatric acute lung injury consensus conference definition.

The recently developed Montreux definition for neonatal acute respiratory distress syndrome (ARDS) partially differs from the Second Pediatric Acute Lung Injury Consensus Conference (PALICC-2) definition. Here, we compare the Montreux and PALICC-2 definitions regarding morbidity, mortality, and prognosis of neonatal cases of ARDS in order to evaluate which definition is more appropriate for newborns. Neonates admitted to our neonatal intensive care unit between 1 January 2018 and 30 September 2019 who met the Montreux or PALICC-2 definition of neonatal ARDS were retrospectively analyzed (n = 472). One comparison was made between application of the Montreux and PALICC-2 definitions to neonates outside the perinatal period (> 7 d after birth). A second comparison was made between a diagnosis of neonatal ARDS within (≤ 7 d of birth) and outside (> 7 d after birth) the perinatal period using the Montreux definition. No significant differences in morbidity, mortality, severity, therapies, or prognosis were observed between neonates in the extra perinatal group according to the Montreux and PALICC-2 definitions. However, epidemiology, clinical course, and prognosis of neonatal ARDS within the perinatal period did differ from those outside the perinatal period according to the Montreux definition. Neonates with ARDS within the perinatal period have unique triggers, epidemiology, clinical course, and prognosis, yet a similar pathobiology pattern, to neonates at other ages. Therefore, it may be essential to consider the perinatal period when defining neonatal ARDS.

Prevalence and Incidence of Pediatric Acute Respiratory Distress Syndrome in a Tertiary Academic PICU in South Africa.

To determine the prevalence and incidence of pediatric acute respiratory distress syndrome (pARDS) among infants and children admitted to the PICU. A single-center descriptive point prevalence study with twice weekly data collection over a 6 months (August 2020 to February 12, 2021). Red Cross War Memorial Children's Hospital, Cape Town, South Africa. All infants and children admitted to the PICU on study days were included. Data were captured electronically on a standardized case record form using a Research Electronic Data Capture electronic database. The Pediatric Acute Lung Injury Consensus Conference criteria were used to define pARDS cases. Prevalence was calculated as the total number of pARDS cases/1,000 PICU bed days. The study included 354 patients (median [interquartile range]) 10.1 months old (1.5-61.3 mo old), with 204 males (57.6%), who occupied 879 bed days. Of these 879 bed days, 266 (30.3%; 95% CI, 27.2-33.3%) were occupied by pARDS cases, with a calculated prevalence and incidence of 302.6 of 1,000 bed days (30.3%) and 29.7% (95% CI, 26.7-32.7%), respectively. Three cases from the cohort were defined using the oxygen saturation index calculation. In cases receiving invasive ventilation ( n = 494; 56.2%), pARDS severity was classified as mild ( n = 143; 16.3%), moderate ( n = 44; 5.0%), and severe ( n = 29, 3.3%). A further 205 beds (23.3%) were occupied by patients classified as being at risk of pARDS. The prevalence and incidence of pARDS in a South African PICU appears substantially higher than findings described in international reports. Further investigation of risk factors and outcomes is warranted.

Interrater Reliability of the 2015 Pediatric Acute Lung Injury Consensus Conference Criteria for Pediatric ARDS

Diagnostic guidelines for pediatric acute respiratory distress syndrome (PARDS) were developed at the 2015 Pediatric Acute Lung Injury Consensus Conference (PALICC). Although this was an improvement in creating pediatric-specific diagnostic criteria, there remains potential for variability in identification of PARDS. What is the inter-rater reliability of the 2015 PALICC criteria for diagnosing moderate-severe PARDS? What clinical criteria and patient factors are associated with diagnostic disagreements? Patients with acute hypoxic respiratory failure admitted from 2016-2021 who received invasive mechanical ventilation were retrospectively reviewed by two PICU physicians. Reviewers evaluated whether the patient met the 2015 PALICC definition of moderate-severe PARDS and rated their diagnostic confidence. Inter-rater reliability was measured using Gwet's Agreement Coefficient (AC1). 37 of 191 encounters had a diagnostic disagreement. Inter-rater reliability was "substantial" (AC1=0.74, 95% CI [0.65 - 0.83]). Disagreements were due to different interpretations of chest radiographs (56.8%), ambiguity in origin of pulmonary edema (37.8%), or lack of clarity if patient's current condition was significantly different from baseline (27.0%). Disagreement was more likely in patients who were chronically ventilated (OR 4.66, 95% CI [2.16-10.08], p<0.001), had a primary cardiac admission diagnosis (OR 3.36, 95% CI [1.18 - 9.53], p=0.02), or underwent cardiothoracic surgery during the admission (OR 4.90, 95% CI [1.60 - 15.00], p=0.005). Reviewers were at least moderately confident in their decision 73% of the time, however were less likely to be confident if the patient had cardiac disease or chronic respiratory failure. The inter-rater reliability of the 2015 PALICC criteria for diagnosing moderate-severe PARDS in this cohort was substantial, with diagnostic disagreements commonly due to differences in chest radiograph interpretations. Patients with cardiac disease or chronic respiratory failure were more vulnerable to diagnostic disagreements. More guidance is needed on interpreting chest radiographs and diagnosing PARDS in these subgroups.

CLINICO-ETIOLOGICAL PROFILE AND OUTCOME OF ACUTE RESPIRATORY DISTRESS SYNDROME IN PAEDIATRIC INTENSIVE CARE UNIT (PICU) IN A TERTIARY CARE HOSPITAL IN BHUBANESWAR.

Objective:-To study the clinical profile of the patients of acute respiratory distress syndrome (ARDS) in terms of etiology and clinical course &amp; to evaluate the outcome of the patients with ARDS in term of mortality. :- Study design Prospective observational study. Study was conducted in PICU of HI-Tech medical college, Bhubaneswar. Study group:- All children aged between 3months to 12yrs admitted in PICU from 1st sep 2020 to 31 august 2022,with a diagnosis of pediatric acute respiratory distress syndrome as per pediatric acute lung injury consensus conference definition (PLICC). - Out of 130 patients having acute respiratory distress syndrome, 64.6% Measurements &amp; main results: expired in PICU during stay &amp; 35.3% were discharged. Out of admitted 60% were male &amp; 40 % were female. Most common primary etiology was Pneumonia followed by sepsis, other causes may be drowning, trauma, burns, transfusion related acute lung injury. Pediatric acute respiratory distress syndrome contributes to a significa Conclusion:- nt burden in the PICU of developing country and is associated with significant high mortality. Infection remains the most common etiology.

Association of Interventions With Outcomes in Children At-Risk for Pediatric Acute Respiratory Distress Syndrome: A Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology Study.

Describe the frequency with which transfusion and medications that modulate lung injury are administered to children meeting at-risk for pediatric acute respiratory distress syndrome (ARF-PARDS) criteria and evaluate for associations of transfusion, fluid balance, nutrition, and medications with unfavorable clinical outcomes. Secondary analysis of the Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology study, a prospective point prevalence study. All enrolled ARF-PARDS patients were included unless they developed subsequent pediatric acute respiratory distress syndrome (PARDS) within 24 hours of PICU admission or PICU length of stay was less than 24 hours. Univariate and multivariable analyses were used to identify associations between therapies given during the first 2 calendar days after ARF-PARDS diagnosis and subsequent PARDS diagnosis (primary outcome), 28-day PICU-free days (PFDs), and 28-day ventilator-free days (VFDs). Thirty-seven international PICUs. Two hundred sixty-seven children meeting Pediatric Acute Lung Injury Consensus Conference ARF-PARDS criteria. None. During the first 2 days after meeting ARF-PARDS criteria, 55% of subjects received beta-agonists, 42% received corticosteroids, 28% received diuretics, and 9% were transfused. Subsequent PARDS (15%) was associated with platelet transfusion (n = 11; adjusted odds ratio: 4.75 [95% CI 1.03-21.92]) and diuretics (n = 74; 2.55 [1.19-5.46]) in multivariable analyses that adjusted for comorbidities, PARDS risk factor, initial oxygen saturation by pulse oximetry:Fio2 ratio, and initial type of ventilation. Beta-agonists were associated with lower adjusted odds of subsequent PARDS (0.43 [0.19-0.98]). Platelets and diuretics were also associated with fewer PFDs and fewer VFDs in the multivariable models, and TPN was associated with fewer PFDs. Corticosteroids, net fluid balance, and volume of enteral feeding were not associated with the primary or secondary outcomes. There is an independent association between platelet transfusion, diuretic administration, and unfavorable outcomes in children at risk for PARDS, although this may be related to treatment bias and unmeasured confounders. Nevertheless, prospective evaluation of the role of these management strategies on outcomes in children with ARF-PARDS is needed.

Nutritional Support in Children Meeting the At-Risk for Pediatric Acute Respiratory Distress Syndrome Criteria.

To examine associations between early enteral nutrition (EN) and PICU outcomes in a cohort of children meeting the 2015 Pediatric Acute Lung Injury Consensus Conference "at-risk" for pediatric acute respiratory distress syndrome (ARF-PARDS) criteria. This was a single-center, electronic health record-based retrospective chart review. We included children less than or equal to 18 years-old admitted to our mixed medical-surgical PICU from January 2017 to December 2018 who met ARF-PARDS criteria within 48 hours of admission. Children were categorized as receiving "early" EN if feeds were initiated within 48 hours of admission. All others were categorized as "delayed" EN. Extracted data included demographics, illness characteristics including primary diagnosis and Pediatric Risk of Mortality (PRISM) III score, respiratory support and oxygenation indices, nutritional data, and PICU length of stay (LOS). The primary outcome of interest was subsequent diagnosis of PARDS. Of 201 included children, 152 (75.6%) received early EN. The most common admission diagnoses were pneumonia, bronchiolitis, and influenza. Overall, 21.4% (n = 43) of children developed PARDS. Children receiving early EN had a subsequent diagnosis of PARDS less often then children receiving delayed EN (15.1% vs 40.8%; p < 0.001), an association that persisted after adjusting for patient demographics and illness characteristics, including PRISM III and diagnosis (adjusted odds ratio, 0.24; 95% CI, 0.10-0.58; p = 0.002). Early EN was also associated with a shorter PICU LOS in univariate analysis (2.2 d [interquartile range, 1.5-3.4 d] vs 4.2 d [2.7-8.9 d]; p < 0.001). In this single-center, retrospective cohort study, compared with children with ARF-PARDS who received late EN, those who received early EN demonstrated a reduced odds of subsequent diagnosis of PARDS, and an unadjusted reduction in PICU LOS when compared with delayed EN. Prospective studies should be designed to confirm these findings.

Invasive Ventilatory Support in Patients With Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference.

To provide evidence for the Second Pediatric Acute Lung Injury Consensus Conference updated recommendations and consensus statements for clinical practice and future research on invasive mechanical ventilation support of patients with pediatric acute respiratory distress syndrome (PARDS). MEDLINE (Ovid), Embase (Elsevier), and CINAHL Complete (EBSCOhost). We included clinical studies of critically ill patients undergoing invasive mechanical ventilation for PARDS, January 2013 to April 2022. In addition, meta-analyses and systematic reviews focused on the adult acute respiratory distress syndrome population were included to explore new relevant concepts (e.g., mechanical power, driving pressure, etc.) still underrepresented in the contemporary pediatric literature. Title/abstract review, full text review, and data extraction using a standardized data collection form. The Grading of Recommendations Assessment, Development and Evaluation approach was used to identify and summarize relevant evidence and develop recommendations, good practice statements and research statements. We identified 26 pediatric studies for inclusion and 36 meta-analyses or systematic reviews in adults. We generated 12 recommendations, two research statements, and five good practice statements related to modes of ventilation, tidal volume, ventilation pressures, lung-protective ventilation bundles, driving pressure, mechanical power, recruitment maneuvers, prone positioning, and high-frequency ventilation. Only one recommendation, related to use of positive end-expiratory pressure, is classified as strong, with moderate certainty of evidence. Limited pediatric data exist to make definitive recommendations for the management of invasive mechanical ventilation for patients with PARDS. Ongoing research is needed to better understand how to guide best practices and improve outcomes for patients with PARDS requiring invasive mechanical ventilation.

Monitoring in Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference.

Monitoring is essential to assess changes in the lung condition, to identify heart-lung interactions, and to personalize and improve respiratory support and adjuvant therapies in pediatric acute respiratory distress syndrome (PARDS). The objective of this article is to report the rationale of the revised recommendations/statements on monitoring from the Second Pediatric Acute Lung Injury Consensus Conference (PALICC-2). MEDLINE (Ovid), Embase (Elsevier), and CINAHL Complete (EBSCOhost). We included studies focused on respiratory or cardiovascular monitoring of children less than 18 years old with a diagnosis of PARDS. We excluded studies focused on neonates. Title/abstract review, full-text review, and data extraction using a standardized data collection form. The Grading of Recommendations Assessment, Development and Evaluation approach was used to identify and summarize evidence and develop recommendations. We identified 342 studies for full-text review. Seventeen good practice statements were generated related to respiratory and cardiovascular monitoring. Four research statements were generated related to respiratory mechanics and imaging monitoring, hemodynamics monitoring, and extubation readiness monitoring. PALICC-2 monitoring good practice and research statements were developed to improve the care of patients with PARDS and were based on new knowledge generated in recent years in patients with PARDS, specifically in topics of general monitoring, respiratory system mechanics, gas exchange, weaning considerations, lung imaging, and hemodynamic monitoring.

Definition, Incidence, and Epidemiology of Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference.

In 2015, the Pediatric Acute Lung Injury Consensus Conference (PALICC) provided the first pediatric-specific definitions for acute respiratory distress syndrome (pediatric acute respiratory distress syndrome [PARDS]). These definitions have since been operationalized in cohort and interventional PARDS studies. As substantial data have accrued since 2015, we have an opportunity to assess the construct validity and utility of the initial PALICC definitions. Therefore, the Second PALICC (PALICC-2) brought together multiple PARDS experts and aimed to identify and summarize relevant evidence related to the definition and epidemiology of PARDS and create modifications to the definition of PARDS. MEDLINE (Ovid), Embase (Elsevier), and CINAHL Complete (EBSCOhost). We included studies of subjects with PARDS, or at risk for PARDS, excluding studies pertaining primarily to adults except as specified for identifying age-specific cutoffs. Title/abstract review, full-text review, and data extraction using a standardized data collection form. The Grading of Recommendations Assessment, Development, and Evaluation approach was used to identify and summarize evidence and develop recommendations. A total of 97 studies were identified for full-text extraction addressing distinct aspects of the PARDS definition, including age, timing, imaging, oxygenation, modes of respiratory support, and specific coexisting conditions. Data were assessed in a Patient/Intervention/Comparator/Outcome format when possible, and formally summarized for effect size, risk, benefit, feasibility of implementation, and equity. A total of 17 consensus-based definition statements were made that update the definition of PARDS, as well as the related diagnoses of "Possible PARDS" and "At-Risk for PARDS." These statements are presented alongside a summary of the relevant epidemiology. We present updated, data-informed consensus statements on the definition for PARDS and the related diagnoses of "Possible PARDS" and "At-Risk for PARDS."

Pulmonary Specific Ancillary Treatment for Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference.

We conducted an updated review of the literature on pulmonary-specific ancillary therapies for pediatric acute respiratory distress syndrome (PARDS) to provide an update to the Pediatric Acute Lung Injury Consensus Conference recommendations and statements about clinical practice and research. MEDLINE (Ovid), Embase (Elsevier), and CINAHL Complete (EBSCOhost). Searches were limited to children, PARDS or hypoxic respiratory failure and overlap with pulmonary-specific ancillary therapies. Title/abstract review, full-text review, and data extraction using a standardized data collection form. The Grading of Recommendations Assessment, Development, and Evaluation approach was used to identify and summarize evidence and develop recommendations. Twenty-six studies were identified for full-text extraction. Four clinical recommendations were generated, related to use of inhaled nitric oxide, surfactant, prone positioning, and corticosteroids. Two good practice statements were generated on the use of routine endotracheal suctioning and installation of isotonic saline prior to endotracheal suctioning. Three research statements were generated related to: the use of open versus closed suctioning, specific methods of airway clearance, and various other ancillary therapies. The evidence to support or refute any of the specific ancillary therapies in children with PARDS remains low. Further investigation, including a focus on specific subpopulations, is needed to better understand the role, if any, of these various ancillary therapies in PARDS.

Editor's Choice Articles for February.

February 2023 of Pediatric Critical Care Medicine (PCCM) is an issue worthy of this year’s Society of Critical Care Medicine (SCCM) annual conference. All content is excellent, but my focus this month is to highlight two Late Breaker articles (i.e., not previously published ahead of print) and a Special Article as my Editor’s Choices (1–3), and to draw your attention to this month’s PCCM Connections with another focus on Respiratory Critical Care Practice. WHAT IS THE POTENTIAL IMPACT OF WITHHOLDING TRANSFUSION IN HEMODYNAMICALLY STABLE CHILDREN WITHOUT CARDIAC DISEASE AND HEMOGLOBIN ABOVE 7 G/DL? Steffen KM, Tucci M, Doctor A, et al; Pediatric Critical Care Blood Research Network (BloodNet) subgroup of the Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network: The Impact of Restrictive Transfusion Practices on Hemodynamically Stable Critically Ill Children Without Heart Disease: A Secondary Analysis of the ABC-PICU Trial (1). My first Editor’s Choice article is the first PCCM late breaker report for the SCCM meeting. The authors have performed a nonprespecified, secondary analysis of transfusion and outcomes data in over 650 children from 50 international centers recruited (2014−2018) in the age of blood in children in PICUs (ABC-PICU) trial. Our authors are particularly interested in one of the recommendations of the 2018 consensus from the Transfusion and Anemia Expertise Initiative (TAXI), i.e., the red blood cell transfusion threshold of < 7 g/dL (4). Read the article to find out the theoretical consequence of compliance with restrictive transfusion in hemodynamically stable patients on two outcomes (PICU-free and ventilator-free days), and the likely associated odds of new or progressive multiorgan system dysfunction. The editorial provides us with important insight into this post hoc analysis of the ABC-PICU data, as well as giving readers the additional context of implementing the TAXI guidance (5). WHAT DO WE KNOW ABOUT LONG-TERM CONSEQUENCES OF POST-TRAUMATIC STRESS DISORDER IN PARENTS OF PICU PATIENTS? Whyte-Nesfield MW, Kaplan D, Eldridge P, et al: Pediatric Critical Care Associated Parental Traumatic Stress: Beyond the First Year (2). My second Editor’s Choice and late breaker article is a prospective PICU follow-up study of approximately 200 parents who completed assessments about post-traumatic stress (PTS). The study addresses two very important issues: 1) the detrimental effects of acute and subacute parental PTS up to 30 months after PICU discharge; and 2) the identifiable explanatory factors that may be targets for help and mitigation. The editorial is written by one of PCCM’s much valued experts in clinical psychology, and the challenge for us is whether it is time for “the Trauma Informed PICU” (6). WHAT ARE THE CONTEMPORARY INTERNATIONAL GUIDELINES FOR THE DIAGNOSIS AND MANAGEMENT OF PEDIATRIC ACUTE RESPIRATORY DISTRESS SYNDROME? Emeriaud G, López-Fernandez YM, Iyer NP, et al; Second Pediatric Acute Lung Injury Consensus Conference (PALICC-2) for the Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network: Executive Summary of the Second Guidelines for the Diagnosis and Management of Pediatric Acute Respiratory Distress Syndrome (PALICC-2) (3). My third Editor’s Choice article is a Special Article for PCCM that summarizes the work of the second pediatric acute lung injury consensus conference (PALICC-2) group. In this article, 52 international experts have collaborated to update the PALICC 2015 guidelines for pediatric acute respiratory distress syndrome (PARDS) using literature searches through to April 2022. We now have 146 recommendations and statements. PCCM has devoted an extended-page format to this outstanding and important content. In addition to the text and narrative, you will find excellent summaries in tables and figures. There is a full supplement accompanying this issue of PCCM, with 12 articles on specialist topic areas that inform the executive summary. In conjunction, this work represents the 2023 benchmark of 1980 to 2022 data about PARDS. “PCCM CONNECTIONS” FOR READERS The publication of PALICC-2 (3) also provides us with another opportunity to focus on respiratory critical care practice (see also the December 2022 issue). First, we have a feature article (7), with an editorial (8), about critical care and invasive mechanical ventilation (IMV) practices surrounding liver transplantation. The retrospective analysis comes from 12 PICUs in the U.S. and looks at the time course of IMV in 330 children. The editorial helps us to better understand the range in use of IMV in this setting. Second, we have a database study using the Pediatric Health Information System in the U.S (9). In this article the authors have focused on the timing of tracheostomy at 52 children’s hospitals in over 10,000 children, in the period 2010 to 2020. This unique report is a major resource and needs to be read in conjunction with PCCM’s recent articles on tracheostomy and prolonged IMV (10–14). Third, it is back to the all-important topic of bronchiolitis and supportive respiratory care. We have two systematic reviews: one on noninvasive ventilation (NIV) in acute respiratory failure–four of 15 articles were about bronchiolitis care (15); the other on use of high-flow nasal cannula (HFNC) oxygen therapy or NIV in 28 reports of bronchiolitis (16). We also have a retrospective study of oxygen exposure during IMV in 176 patients with bronchiolitis, in which the authors are interested in oxygen overuse and the potential for optimal oxygenation targets (17). In this context, please look at the recently published protocol for the randomized controlled trial on conservative versus liberal oxygenation targets in critically ill children (18). To close these readings on bronchiolitis, have a look at the single-center quality improvement initiative on using a protocol for the initiation and weaning of HFNC oxygen for patients with bronchiolitis (19). Accompanying this article, our editorial describes a robust and cogent call to action (20). Finally, I am pleased to highlight two narrative reviews on the topic of respiratory critical care practice that will be useful additions to your reading of the PALICC-2 guidelines (3). First, go back to the December 2022 issue and the review on “clinical challenges of pediatric ventilation liberation” (21). Next, read the beautifully illustrated PCCM Concise Clinical Physiology Review on approaches to mechanical ventilation for patients with PARDS (22).

Methodology of the Second Pediatric Acute Lung Injury Consensus Conference.

This article describes the methodology used for The Second Pediatric Acute Lung Injury Consensus Conference (PALICC-2). The PALLIC-2 sought to develop evidence-based clinical recommendations and when evidence was lacking, expert-based consensus statements and research priorities for the diagnosis and management of pediatric acute respiratory distress syndrome (PARDS). Electronic searches were conducted using PubMed, Embase, and Cochrane Library (CENTRAL) databases from 2012 to March 2022. Content was divided into 11 sections related to PARDS, with abstract and full text screening followed by data extraction for studies which met inclusion with no exclusion criteria. We used a standardized data extraction form to construct evidence tables, grade the evidence, and formulate recommendations or statements using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. This consensus conference was comprised of a multidisciplinary group of international experts in pediatric critical care, pulmonology, respiratory care, and implementation science which followed standards set by the Institute of Medicine, using the GRADE system and Research And Development/University of California, Los Angeles appropriateness method, modeled after PALICC 2015. The panel of 52 content and four methodology experts had several web-based meetings over the course of 2 years. We conducted seven systematic reviews and four scoping reviews to cover the 11 topic areas. Dissemination was via primary publication listing all statements and separate supplemental publications for each subtopic that include supporting arguments for each recommendation and statement. A consensus conference of experts from around the world developed recommendations and consensus statements for the definition and management of PARDS and identified evidence gaps which need further research.

Noninvasive Respiratory Support for Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference.

To develop evidence-based recommendations for the Second Pediatric Acute Lung Injury Consensus Conference (PALICC) regarding the effectiveness of noninvasive respiratory support for pediatric acute respiratory distress syndrome (PARDS). These include consideration of the timing and duration of noninvasive ventilation (NIV) and high-flow nasal cannula (HFNC), whether effectiveness varies by disease severity or by characteristics of treatment delivery, and best practices for the use of NIV. MEDLINE (Ovid), Embase (Elsevier), and CINAHL Complete (EBSCOhost). Searches included all studies involving the use of NIV or HFNC in children with PARDS or hypoxemic respiratory failure. Title/abstract review, full-text review, and data extraction using a standardized data extraction form. The Grading of Recommendations Assessment, Development, and Evaluation approach was used to identify and summarize evidence and develop recommendations. Out of 6,336 studies, we identified 187 for full-text review. Four clinical recommendations were generated, related to indications, timing and duration of NIV in patients with PARDS, predictors of NIV failure and need for intubation (signs and symptoms of worsening disease including pulse oximetry saturation/Fio2 ratio), and use of NIV in resource-limited settings. Six good practice statements were generated related to how and where to deliver NIV, the importance of trained experienced staff and monitoring, types of NIV interfaces, the use of sedation, and the potential complications of this therapy. One research statement was generated related to indications of HFNC in patients with PARDS. NIV is a widely used modality for the treatment of respiratory failure in children and may be beneficial in a subset of patients with PARDS. However, there needs to be close monitoring for worsening disease and NIV failure.

Executive Summary of the Second International Guidelines for the Diagnosis and Management of Pediatric Acute Respiratory Distress Syndrome (PALICC-2).

We sought to update our 2015 work in the Second Pediatric Acute Lung Injury Consensus Conference (PALICC-2) guidelines for the diagnosis and management of pediatric acute respiratory distress syndrome (PARDS), considering new evidence and topic areas that were not previously addressed. International consensus conference series involving 52 multidisciplinary international content experts in PARDS and four methodology experts from 15 countries, using consensus conference methodology, and implementation science. Not applicable. Patients with or at risk for PARDS. None. Eleven subgroups conducted systematic or scoping reviews addressing 11 topic areas: 1) definition, incidence, and epidemiology; 2) pathobiology, severity, and risk stratification; 3) ventilatory support; 4) pulmonary-specific ancillary treatment; 5) nonpulmonary treatment; 6) monitoring; 7) noninvasive respiratory support; 8) extracorporeal support; 9) morbidity and long-term outcomes; 10) clinical informatics and data science; and 11) resource-limited settings. The search included MEDLINE, EMBASE, and CINAHL Complete (EBSCOhost) and was updated in March 2022. Grading of Recommendations, Assessment, Development, and Evaluation methodology was used to summarize evidence and develop the recommendations, which were discussed and voted on by all PALICC-2 experts. There were 146 recommendations and statements, including: 34 recommendations for clinical practice; 112 consensus-based statements with 18 on PARDS definition, 55 on good practice, seven on policy, and 32 on research. All recommendations and statements had agreement greater than 80%. PALICC-2 recommendations and consensus-based statements should facilitate the implementation and adherence to the best clinical practice in patients with PARDS. These results will also inform the development of future programs of research that are crucially needed to provide stronger evidence to guide the pediatric critical care teams managing these patients.

Expression Patterns of Airway Fluid Cytokines From Intubated Children With Pediatric Acute Respiratory Distress Syndrome.

Prospective observational cohort study. Single 36-bed quaternary care academic safety-net hospital PICU. Children intubated for acute respiratory failure between January 2018 and November 2021 stratified by Pediatric Acute Lung Injury Consensus Conference-1 criteria for PARDS. None. We measured levels of 23 cytokines, chemokines, and protein biomarkers in the tracheal aspirate from 82 intubated children, between 14 days and 17 years old, at risk for or with PARDS. Levels of interleukin-4, -5, -7, -8, -12(p-70), -17a, -21, and fractalkine were higher in patients with severe versus nonsevere PARDS. There were no associations between airway and plasma cytokines. Proinflammatory cytokines are elevated in the airway fluid from intubated children with severe PARDS and reflect diverse patterns of airway inflammation.

A Comprehensive Review on the Management of ARDS among Pediatric Patients

Pediatric acute respiratory distress syndrome (PARDS) is a complex inflammatory syndrome of lungs leading to disruption of alveolar epithelial membrane barrier in the lungs. It includes varying age groups from infants to adolescents. PARDS definition has changed over decades as current definition is given by the Pediatric Acute Lung Injury Consensus Conference group. Although most of management principles are extrapolated from adult data, physiology of Acute Respiratory Distress Syndrome (ARDS) in children is different when compared to adults. The present review mainly focused on current evidence in the management of ARDS with emphasis to pediatric population. MeSH headings such as ARDS, positive end-expiratory pressure (PEEP), and lung protective ventilation were used for searching publications in PubMed, Embase, and SciELO. Publications were limited to human studies in the past 20 years. Core ventilatory strategies in PARDS include use of low-tidal volume, higher PEEP and acceptance of permissive hypercapnia and permissive hypoxemia. Supportive strategies such as restrictive fluid therapy, prone positioning, early enteral nutrition, and adequate analgosedation remain the mainstay of management of principles. As PARDS contains heterogeneous population, personalized mechanical ventilation under umbrella of lung protective ventilator strategies such as low-tidal volume ventilation, open lung strategy, acceptance of permissive hypercapnia, and permissive hypoxia is standard of care.

P50 implies adverse clinical outcomes in pediatric acute respiratory distress syndrome by reflecting extrapulmonary organ dysfunction

Hypoxemia and multiple organ dysfunction are significant contributors to mortality in patients with pediatric acute respiratory distress syndrome (PARDS). P50, the oxygen tension at which hemoglobin is 50% saturated, is a measure of hemoglobin-oxygen affinity, and its alteration might have implications for tissue hypoxia and organ dysfunction. The purpose of this single-center, retrospective study was to evaluate P50 levels in PARDS and to determine the association between P50 and clinical outcomes. The study included 212 children diagnosed with PARDS according to the Pediatric Acute Lung Injury Consensus Conference definition who required invasive mechanical ventilation and had arterial blood gas results of hemoglobin oxygen saturation < 97% at the time of diagnosis. P50 levels were calculated using Doyle’s method, and organ dysfunction was assessed using the Pediatric Logistic Organ Dysfunction-2 score. Most patients exhibited more than one dysfunctional extrapulmonary organ at PARDS onset. P50 increased with increasing PARDS severity (mild (26.6 [24.9–29.6]), moderate (26.8 [25.0–29.5]), and severe PARDS (29.1 [26.1–32.4] mmHg; P = 0.025). Moreover, P50 demonstrated a significant positive association with extrapulmonary organ dysfunction score (β = 0.158, P = 0.007) and risk of mortality (adjusted hazard ratio, 1.056; 95% confidence interval, 1.015–1.098; P = 0.007), irrespective of initial PARDS severity. The relationship between P50 and mortality was largely mediated by extrapulmonary organ dysfunction. A high P50 value at the time of PARDS diagnosis may be associated with mortality via dysfunctional extrapulmonary organs. Future studies should consider P50 as a potential candidate index for risk stratification of PARDS patients.

Recognizing Pediatric ARDS: Provider Use of the PALICC Recommendations in a Tertiary Pediatric ICU.

For almost 50 years, pediatricians used adult guidelines to diagnose ARDS. In 2015, specific criteria for pediatric ARDS were defined. However, it remains unclear how frequently providers recognize pediatric ARDS and whether recognition affects adherence to consensus recommendations. This was a mixed-method, retrospective study of mechanically ventilated pediatric subjects after the release of the pediatric ARDS recommendation statement. Pediatric ARDS cases were identified according to the new criteria. Provider recognition was defined by documentation in the medical record. Pediatric ARDS subjects with and without provider recognition were compared quantitatively according to clinical characteristics, adherence to lung-protective ventilation (LPV), adjunctive therapies, and outcomes. A qualitative document analysis (QDA) was performed to evaluate knowledge and beliefs surrounding the Pediatric Acute Lung Injury Consensus Conference recommendations. Of 1,983 subject encounters, pediatric ARDS was identified in 321 (16%). Provider recognition was present in 97 (30%) cases and occurred more often in subjects who were older, had worse oxygenation deficits, or were bone marrow transplant recipients. Recognition rates increased each studied year. LPV practices did not differ based on provider recognition; however, subjects who received it were more likely to experience permissive hypoxemia and adherence to extrapulmonary recommendations. Ultimately, there was no differences in outcomes between the provider recognition and non-provider recognition groups. Three themes emerged from the QDA: (1) pediatric ARDS presents within a complex, multidimensional context, with potentially competing organ system failures; (2) similar to historical conceptualizations, pediatric ARDS was often considered a visual diagnosis, with measures of oxygenation unreferenced; and (3) emphasis was placed on non-evidence-based interventions, such as pulmonary clearance techniques, rather than on consensus recommendations. Among mechanically ventilated children, pediatric ARDS was common but recognized in a minority of cases. Potential opportunities, such as an opt-out approach to LPV, may exist for improved dissemination and implementation of recommended best practices.